Since Wednesday afternoon, all phone lines to the Health Department and top district officials in Kerala have remained busy. From the Health Secretary to the medical officers of all 14 districts, officials responding to the coronavirus pandemic in the state are drawing up a war plan, as Kerala hurtles towards it COVID-19 peak.
If the current trend and testing continues, experts warn that Kerala could see up to 1 lakh infections per day by week two of May.
“Our cases here are projected to peak sometime between May 10 - 15 and we could see a maximum test positivity rate (TPR) of 30 %. Worst case scenario, we could see a 35 % TPR, but that looks unlikely now," says Dr KP Aravindan, a pathology expert and member of the State Planning Board for COVID-19. TPR is the percentage of positive cases in a group of samples tested and experts reckon that it is the best measure to determine the rate of spread of the infection.
Kerala’s TPR has been steadily rising. On April 28, it stood at 25.3 %. In comparison, Delhi has had an alarming 40 % test positivity rate in the second wave that has left thousands dead. However, there is no room for complacency.
In the cities of Ernakulam and Kozhikode, record COVID-19 infections this week have led to an alarming situation, CM Pinarayi Vijayan admitted in a recent press meet.
In Thrissur, Kozhikode and Thiruvananthapuram, private and government medical college hospitals are running out of ICU rooms and ventilators as they have reported 90 to 100 % occupancy of their COVID-19 beds. (add link)
But even as this story is being written, the state is building capacity for COVID-19 critical care on a war footing.
Take the example of Ernakulam, a district which is currently treating over 44,000 active COVID-19 cases (highest in the state) weeks before the peak. Suhas Shivanna, Ernakulam’s Collector, tells TNM that factoring in the current scenario, the district administration has tied up with private hospitals to ramp up oxygen beds, ventilators and ICUs.
On Wednesday, the Chief Minister said the oxygen beds will be set up even in taluk hospitals and First Line Treatment Centres or CFLTCs. When TNM spoke to the Ernakulam Collector on Thursday, the district already had 714 oxygen beds in seven taluk hospitals, out of which 446 beds are occupied. Thirty extra oxygen beds will soon be set up in every taluk hospital.
“Over two weeks, we have added 250 additional oxygen beds. Our CFLTCs have 617 beds where we have complete infrastructure to administer oxygen if a patient needs it. Each centre has 2-3 cylinders and beds,” Suhas explains. Further, every Community Health Centre or CHC in the district has five beds each with oxygen cylinders. This is replicated across the state.
This week, the Government Medical College Hospital in Kalamassery, Ernakulam added 140 new oxygen beds for COVID-care. “We also tied up with SNIMS in Paravur, Apollo Adlux hospital in Angamaly and three more private hospitals to add 100 plus oxygen beds,” he adds.
Depending on their projected case loads, similar capacity building is being done in other districts, Suhas added.
Oxygen war room
Each district has also set up COVID-19 control centres, where admissions to government medical colleges is done. Positive patients are triaged and redirected to hospitals, CFLTCs or Domiciliary Care Centres based on the severity of their infection.
Inside the control room in Ernakulam with screens displaying COVID-19 data in district
In Ernakulam district, the control room is dubbed as the ‘Oxygen War Room’ from where all admissions to public hospitals are being streamlined. Officials also update the district's COVID-19 dashboard from this war room.
Rational Admission Policy
It is critical to triage patients for optimum use of COVID-19 resources. When the number of patients is large, triaging is the process through which degrees of urgency are assigned to the condition of the patients and urgent cases are treated on priority. And therefore, setting up oxygen war rooms makes it easier for officials to triage and admit patients who are in need to hospitals.
“This is called the Rational Admission Policy and we are focusing on this in the second wave,” says Dr Amar Fettle, state nodal officer for COVID-19 in Kerala.
His words were reiterated by CM Pinarayi Vijayan who said that a ‘Scientific Admission Standard Operating Procedure’ would be followed in the state.
According to Dr Amar, a section of hospital beds is used up by COVID-19 patients whose conditions do not merit hospital admissions. “These patients are paranoid and admit themselves into hospitals. Or they can afford private hospitals and seek admission, even if their infection may only warrant home isolation,” Dr Amar explains.
In the government sector, the district control room will enforce rational admissions. But the government has also given strict instructions to private hospitals to only admit patients who need help after triaging, while setting aside 75 % of their beds for COVID-19 care.
Another move to ensure beds in treatment centres and hospitals is early discharge, says Dr Amar.
This means that on the third day of a patient turning asymptomatic, they will be discharged from the hospital and sent for home isolation.
“Typically, positive patients are tested once again on the 10th day. Once they turn negative, they are asked to quarantine at home for 7 days. Now, once they stop showing symptoms, patients are discharged [on the third day after turning asymptomatic] and asked to isolate for 7 days. The local body will closely monitor these patients for those days,” Dr Amar adds.
Rerouting ICUs and ventilators
While certain hospitals and medical colleges are reporting more cases and admissions, in other areas, especially in the suburbs, COVID-19 admissions are few. The surplus ventilators from these hospitals will be shifted to crowded medical colleges for COVID-19 patients. “This is how we optimise our existing resources,” Dr Amar says.
As on April 28, the state had 9,826 ICUs and 3,816 ventilators in both private and government hospitals, out of which 1,514 ICUs and 535 ventilators have been occupied by COVID-19 patients. Additional ventilators or High Flow Nasal Oxygen machines will be procured via the Kerala Medical Services Corporation, based on the state’s needs.
Vaccines and oxygen supply
To tackle vaccine shortage, the state cabinet has also approved the purchase of 1 crore doses of COVID-19 vaccine from the open market (70 lakh Covidshield and 30 lakh Covaxin) from May to July.
In terms of oxygen stock, the state’s oxygen usage for COVID-19 treatment stood at 58.1 metric tonne as on April 27, 2021, against a total oxygen availability of 219.22 metric ton.